Thrombosed varicoceles have been described as a rare cause of acute scrotal pain [
2‐
4]. Postoperative thrombus in pampiniform plexuses have been managed conservatively with intravenous antibiotics, parenteral and oral analgesics, scrotal elevation with bed rest [
3]. Spontaneously occurring thrombi have also been reported to have been managed medically in a previous case, though the exact details of medical treatment are unclear [
2,
4]. As of date, all the cases mentioned in literature have been managed medically without any note of the surgical treatment needed in such cases. It is interesting to note the first report in literature by Roach et al. They had recommended conservative management. In their study of 2patients, both underwent surgical ligation and excision of the thrombosed vein [
7]. So their recommendations are contrary to their findings. Similarly El Hennawy et al. advice conservative management, when in their case they subjected the patient to surgery [
8]. There are 2 other case reports which have reported that pain usually subsides with a week of non-steroidal anti-inflammatory medications and scrotal rest. Here also, Doerfler et al. recommend medical management, while their patient was subjected to surgery [
2]. Kleinclauss et al. were the only ones who managed their patient successfully with medical management alone [
4]. The other documentation of medical management is in that of post-operative Varicocelectomy patients. Summation of all the reports make us come to a conclusion that medical therapy may be successful if only a single superficial spermatic vein is involved, while in cases like ours where the majority of pampiniform plexus is thrombosed, surgical management will have a better outcome. This conclusion is similar to the one by Bolat et al. who opined that treatment can be started conservatively, with surgical intervention reserved for failed cases on an emergent basis [
5]. Similarly Isenberg et al. advice that though venography, Doppler can be diagnostic, surgery should not be delayed in doubtful cases [
9]. Hence, we feel that if severe pain persists in spite of adequate medical therapy (non-steroidal anti-inflammatory agents, scrotal elevation and rest for 7-10 days), as seen in our case, then these patients should be subjected to immediate surgical exploration. Varicocelectomy gives complete pain relief and should be considered as treatment of choice in this sub group of patients, who have failed medical management. Another controversial issue is whether to perform just ligation of the vein or to completely excise the segment of the thrombosed vein? Mallat et al. also reported a case where they had done complete excision of the thrombosed vein [
10]. We also did surgical excision of the thrombosed vein as we felt that doing a simple ligation may not alleviate the pain completely. Another worrisome consideration is that delay in performing Varicocelectomy may probably lead to ischemic damage to the testis. Roach et al. had to perform orchiectomy due to severe venous congestion and testicular ischemia in one of their patients [
7]. Hence, we postulate that in patients with severe scrotal pain not subsiding with 7 days of medical therapy, exploration and varicocelectomy should be immediately considered and may result in salvage of the testis. The second issue in these patients are do thrombi occur in varicoceles? As seen in our case, it is pretty clear that spontaneous thrombosis do occur in varicoceles. The histopathology can help in differentiating an in vivo thrombus from an in vitro post operative clot. A long standing clot in Varicocelectomy specimen of infertility will remodel and have a retraction space, while the clot in thrombosed specimen may not have this space due to the acuteness of the episode.